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How do we reduce drug errors?

21 January, 2008

Medication errors are not uncommon and often go unrecognised and unreported. Ingrid Torjesen looks at key precautions nurses can take to avoid mistakes.

Medication mistakes are unfortunately not rare events. National Patient Safety Agency research shows that almost one in ten inpatients experience medication-related harm. However, many mistakes go unreported as staff often do not realise an error has occurred.The NPSA defines a medication error as an error in the process of prescribing, dispensing, preparing, administering, monitoring or providing medicine advice, regardless of whether any harm has occurred.

Gerry Armitage, senior research fellow at the Bradford Institute of Health Research, says: ‘A nurse might assume that giving a drug late is not an error but it is. In actual fact, it could be an adverse event if the patient has Parkinson’s disease.’A patient having to wait three hours before they can go home because someone has forgotten their drugs could also be an adverse event, he adds.

There are two forms of medication error – adverse events, and ‘near misses’ where no harm has occurred or the incident has been averted.Near misses are considered very useful for learning in the aviation and petrochemical industries but the NHS is not very good at reporting them.

Mr Armitage, who has been funded by the Department of Health to study medication errors, explains: ‘What we don’t sometimes pick up on is that near misses are quite attractive to report because you are not going to get told off but it gives the organisation an opportunity to understand how the recovery of an error took place.’

Up to 9% of inpatients experience medication-related harm, much of which is preventable. Last year the NPSA analysed 60,000 medication incidents reported through the National Reporting and Learning System between January 2005 and June 2006. While 80% of these patients were unharmed, 92 suffered severe harm or died.

The NPSA calculated that preventable medication errors cost the NHS more than £750m each year in England. It found that opioids, anticoagulants, anaesthetics, insulin, antibiotics chemotherapy, antipsychotics and infusion fluids are the most likely medicines to be involved.

Two groups of patients are particularly vulnerable – those with allergies to medications and children. Children are three times more at risk of errors than adults because of the complex dose calculations they require.

The analysis also revealed more than half of errors concern incorrect dosage, strength or frequency of medicine, incorrect drugs or failure to administer medication. Other errors relate to wrong quantity, known allergy, patients being given drugs intended for another patient, incorrect labelling, poor storage and out-of-date stock.

Mr Armitage, who recently developed the Bradford Drug Error Reporting System to identify factors contributing to an incident and how they relate to one another, says many factors are involved. ‘Slips’, such as pressing the wrong button on an IV pump, occur more frequently when a nurse is distracted or under pressure.

‘Overarching and underpinning all this there could be systems issues, like a chronic mismanagement of observation duty or the skills-mix isn’t as it should be,’ he says. ‘Alternatively, there could be cultural issues where, in a given unit, the nurses don’t take the job as seriously as they might.’

Dispensing is associated with the fewest errors during the medication process, followed by prescribing and administration, Mr Armitage explains. ‘One proven way to prevent errors is to have a pharmacist actively engaged on the shop floor working with nurses and doctors. They are particularly good at picking up prescribing errors which nurses inherit.’

Errors can also be reduced by ensuring that the general principles of standardisation and simplification are followed.‘A great example of those maxims is how a drug chart might be designed,’ Mr Armitage says.‘If there are 30 types of drug chart in a trust, that predisposes it to errors because nurses might move around wards and have to change their thinking.’

Questioning ‘and not blindly following rank’ is also vital, he says. ‘Questioning is commonplace in the aviation industry but a junior nurse might feel uncomfortable questioning a senior doctor and asking: is this prescription right? Ultimately, it is in the interestsof patient safety.’

Barbara Stuttle, executive nurse at South West Essex PCT and chairperson of the Association for Nurse Prescribing, says: ‘An error isn’t a problem providing you own up, ensure the patient is safe and the doctors are advised.‘Where nurses have made mistakes, cover up and lie, and all they are worried about is their own neck rather than the patient, that is wrong. That happens when people are fearful of their jobs.’

Molly Courtenay, RCN joint prescribing adviser and professor of prescribing and medicines management at the University of Reading, says the NPSA is trying to develop a no-blame culture to encourage error reporting. ‘Mistakes happen all along the way and you can’t just blame the one person at the end who happens to have administered the medicine,’ she says. ‘The only way we can actually understand how the errors are made is if people can own up to them and you can examine why they’ve occurred.’

The RCN’s other prescribing adviser, Matt Griffiths, who is visiting professor in prescribing and medicines management at the University of Northampton, says that unfortunately some trusts continue to take a punitive approach to errors.‘If there have been genuine mistakes and people have been open and honest about it and are attempting to put the errors right, trusts should be encouraging that kind of open attitude because it encourages more staff to come forward.‘If people are treated in a punitive way after reporting an error, it can make staff reluctant to report,’ he says.

Mr Griffiths warns that if errors are not reported, patients will not receive additional treatment they might require and thereis a danger that the same error could occur again becausethe root cause of the problem – perhaps inadequate trainingor supervision – will not have been addressed.

Six key ways in which nurses can help to reduce medication errors

Report all ‘near misses’ and medication errors, regardless of whether the patient is harmed, to ensure a learning experience

Ensure drugs are administered to the correct patient by checking the wristband and highlight antibiotic allergies on the wristband as well as the drug chart

Check the name and dosage of the medicine to be administered against the prescription

Do not check medicines and their dosages verbally in tandem with other staff to avoid talking each other through mistakes.

Do it separately

Turn the drug administration into protected time and highlight this by wearing a bright tabard

Don’t be afraid to question other staff members, however senior, if you suspect something is not correct

Double-checking of medicines: why the practice sometimes leads to errors

Double-checking of medicines is commonplace and is thought to reduce errors. However, research has shown that it is often a contributory factor to errors if it is not carried out properly. Double-checking can be time-consuming, discourages nurses from taking responsibility for medicines and encourages them to defer to authority.Louise Hardcastle, a clinical role band 5 staff nurse and a sister responsible for practice development at the neonatal unit at Bradford Royal Infirmary, was instrumental in abandoning double-checking of simple drugs at her unit after hearing a presentation from senior research fellow Gerry Armitage about the problems associated with it.In her practice development role, she discussed with other nurses on the unit what they thought and found out what changes to practice they would be comfortable with. Everyone was happy to abandon double-checking simple drugs used routinely, such as erythromycin, sodium chloride and caffeine.‘We were finding it really difficult to find someone to double-check with during a shift, which led to extra errors because people were not actually looking at it – they were sort of glancing and agreeing,’ Ms Hardcastle says. ‘We were talking each other through mistakes.’All IV drugs are still double-checked, but separately. The treating nurse checks the drugs then another member of staff checks them. The first nurse then returns and administers them.She says the nurses are confident in this and are now a lot happier. ‘It gives them more time because they are actually checking them on their own and they are more vigilant about the checking because they know there is no one else to back them up.’Errors in the unit have come down and Ms Hardcastle says she hopes to assess the actual incidence of different errors before and after the systems were changed as part of a master’s degree.